High-risk pregnancy

Hypertension in pregnancy can arise as a new condition resulting from the pregnancy, or on the basis of existing hypertension in the mother. Blood pressure is considered raised when it is above 140/90 mmHg, that is, when the systolic (upper) value is 30 mmHg higher, or the diastolic (lower) value is 15 mmHg higher, than usual.

Treatment differs from that outside pregnancy, because the most common groups of antihypertensive drugs cannot be used owing to their possible harmful effect on the fetus. Besides hygienic and dietary measures, central antihypertensives are mostly used (Methyldopa, a drug that acts on the central nervous system).

The dose and type of treatment can be decisive, so it is necessary to monitor not only blood pressure but a wider range of parameters in the mother and the fetus. This prevents complications caused by treatment that is inadequately chosen or dosed.

Gestational diabetes is a disorder of sugar metabolism that appears during pregnancy. It is diagnosed on the basis of raised fasting blood glucose and/or abnormal values on the glucose tolerance test.

Like other types of diabetes, it is associated with numerous complications of pregnancy, such as heart defects, polyhydramnios and fetal macrosomia. It can be managed with a hygienic and dietary regimen and moderate physical activity. A considerable number of women have a predisposition to this disorder.

In practice, a single test is often considered sufficient, but at check-ups the fetus, the placenta and the amount of amniotic fluid show the real state of the organism. The modern aim is to prevent later obesity, raised blood pressure and diabetes in the child, in early or later life. The condition is easily corrected and treated during pregnancy if it is recognised and treated properly.

Type 1 diabetes mellitus is an autoimmune disorder of sugar metabolism in which the cells of the pancreas do not produce insulin. People with this disease take insulin for life.

During pregnancy, treatment must be adjusted. Hormones produced by the placenta and the fetus, as well as medicines given to mothers to prevent contractions, require dose adjustments and careful monitoring.

More intensive monitoring is necessary, with a multidisciplinary team of endocrinologists and sometimes nephrologists, ophthalmologists and neurologists. If complications of the kidneys, eyes or other organs already exist, the mother’s condition must be adequately balanced before pregnancy is planned. Monitoring of the mother and the fetus continues throughout pregnancy, with the aim of preventing further progression of complications.

For women without complications, with proper care from a perinatology subspecialist and the mother’s discipline, the aim is that the pregnancy leaves no consequences for her health.

Type 2 diabetes mellitus is an acquired disorder of sugar metabolism that is closely linked to obesity. Outside pregnancy it can also be controlled with oral treatment.

Women who conceive in this way are monitored, and treatment is adjusted using a modern approach, so that the disorder does not manifest in either the mother or the fetus.

In such pregnancies it is advisable to be monitored by a perinatology subspecialist in a multidisciplinary way, to ensure the quality of monitoring of the mother and the fetus and an outcome that is good for the health of the mother and the baby.

The thyroid gland regulates the metabolism of the whole body. Disorders may involve increased function (hyperthyroidism) or reduced function (hypothyroidism). Sometimes they are undiscovered before pregnancy and are noted for the first time then.

Pregnancy-related complications most often appear as hyperemesis (intense vomiting), infertility or recurrent miscarriages. Treatment consists of hormone replacement in hypothyroidism and, in hyperthyroidism, the use of their antagonists.

Proper treatment and monitoring of hormone levels are necessary for the child’s later full physical, mental and intellectual development, because hormone levels affect the state of the fetus.

Pathological obesity is a condition in which the BMI (body mass index) is above 30. It is associated with many adverse health outcomes, including infertility and complications of pregnancy such as hypertension and diabetes.

The basic advice for these women is a hygienic and dietary regimen with physical activity, and monitoring of the pregnancy so that complications are detected in good time. When a pregnancy begins with a higher body weight, it is advisable to establish all the details early, so as to avoid the complications that medicine anticipates.

Thanks to ever better treatment options and higher survival in the treatment of malignancy, more and more women become pregnant after a malignant disease.

In managing such pregnancies it is essential to involve an oncologist and offer the patient an individual, multidisciplinary approach. The field of oncofertility is developing, dealing with patients with an active malignancy who wish to continue a pregnancy.

Thrombophilias are haematological diseases with a tendency to form blood clots (thrombi). Inherited thrombophilias result from gene mutations in the genes for proteins involved in the blood clotting (coagulation) system.

They can be responsible for infertility, recurrent miscarriages and late pregnancy losses. They are often discovered only during pregnancy because they cause no obvious symptoms. Careful family and personal history and examination can raise suspicion of this condition.

There are protocols with an individual approach. The circulation between the placenta and the uterus is monitored, along with Doppler of the umbilical artery, and this determines which treatment is applied. Cooperation with a haematologist who knows this narrower field is essential.

Uterine anomalies are disorders in the development of the uterus. They may go unnoticed at regular gynaecological check-ups because they can be subtle and cause no symptoms, yet they often underlie infertility or recurrent miscarriages.

They are corrected by surgical intervention, most often hysteroscopically, as a minimally invasive procedure. Sometimes correction is not needed, and complications can be overcome with appropriate treatment.

Even after correction, follow-up is needed because of the complications that can be expected from the scar left by the intervention.

Endometriosis is a disease in which the endometrium, the inner layer of the uterine wall, grows outside the uterus and forms endometriotic foci.

The disease can go unrecognised for years because it often causes non-specific symptoms such as painful periods, painful intercourse or bowel problems. Endometriosis accounts for a considerable share of the causes of infertility. Symptoms usually ease after a successful pregnancy.

Part of its management is also relief of pain during menstrual bleeding and intercourse.

Pregnancy loss is an extremely painful and emotional experience, and a new attempt to conceive often brings a degree of anxiety.

If recurrent miscarriage is diagnosed (more than two consecutive pregnancy losses), it is advisable to suggest testing for potential known causes, together with investigation of possible causes in the male partner.

A detailed history of earlier miscarriages can give many answers, helps to find a specific cause and avoids unnecessary investigation. The causes investigated include:

• infections
• disorders of the cervical cells
• disorders of the inside of the uterus and uterine anomalies
• genetic causes
• hormonal imbalance
• inherited and acquired thrombophilias
• an imbalance in one of the organ systems that affects the pregnancy indirectly

IVF (in vitro fertilisation), also known as assisted conception, is a treatment for infertility in which egg cells are fertilised with sperm outside the mother’s body. The emotional experience and level of worry are often greater in parents whose pregnancy came about through IVF.

Sometimes the reason for in vitro fertilisation is also a chronic condition of the mother or father, which adds further complications to such pregnancies. Even so, the way the pregnancy is managed and maintained does not differ significantly from a pregnancy conceived naturally.

Pregnancies that follow donation of an egg cell and sperm require a quite different approach. The mother’s body then holds the immunological and genetic make-up of two “new” components, which her body recognises, and it is desirable that it “accepts them adequately” so that the fetus can develop comfortably. The signals the fetus sends to the mother’s body call for appropriate treatment, to avoid additional strain and to help her body adapt.